Office of Environment, Health and Safety (EH&S) - Sanitary Sewer Overflow Incident Form (rev. 07/2016)

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1 STEP 1 Immediately call EH&S at (510) with the following details of the incident: Name of First Responder Phone Number of First Responder Location of Spill Is the spill potentially greater than 1,000? Does the spill have the potential to reach a storm drain, catch basin or the creek? STEP 2 Note your arrival time at the scene (be exact!) Date and Time of Arrival STEP 3 STEP 4 Contain and clean up the overflow. Notify parties if additional assistance is needed. Record the spill end date and time. Spill End Date and Time STEP 5 Fill in the rest of the form and return to EH&S before the end of your shift via one of the following methods: Drop off Hard Copy Fax 317 University Hall #1150 (510) ehs-ep@berkeley.edu Spill Volumes Recovered Spill Volumes Estimated spill volume that reached a separate storm drain that flows to a surface water body from the separate storm drain that flows to the surface water body (do not include water used for cleanup) Estimated spill volume that reached a drainage channel that flows to a surface water body from a drainage channel that flows to a surface water body Estimated spill volume discharged directly to a surface water body from surface water body Estimated spill volume discharged to land (includes inside of buildings) from the discharge to land (do not include water used for cleanup) Estimation Methodology for Spill Volume Eyeball Estimate Method Measured Volume Method Duration and Flow Rate Method Other (explain): Estimation Methodology for Recovered Spill Volume: Eyeball Estimate Method Measured Volume Method Other (explain): 1

2 SPILL VOLUME ESTIMATION WORKSHEET ALL SPILLS Name of Estimator: Picture taken? Dimensions of spill (in ft. or paces): Length Width Depth Additional Notes and Documentation: METHOD 1: EYEBALL ESTIMATE METHOD AND KICK THE BUCKET Imagine amount of water that would spill from a bucket or a barrel. This method is only useful for spills up to 100. Size of bucket(s) or barrel(s) How many of this Multiplier Total Volume Estimated Size of bucket(s) or barrel(s) How many of this Multiplier 1 gal water jug x 1 1 gal water jug x 1 Total Volume Estimated 5 gallon bucket x 5 5 gallon bucket x 5 32 gallon trash can x gallon trash can x gallon drum x gallon drum x 55 Total Volume of Spill Total Volume Recovered METHOD 2: ESTIMATING VOLUME BASED ON SPILL DIMENSIONS If not raining, the shape, dimensions and depth of the spill may be used to estimate the volume. Rectangle: Area = (length) x (width) Circle: Area = (diameter) x (diameter) x Triangle: Area = (base) x (height) x 0.5 Sketch spill with dimensions and calculate average depth. Multiply (area) x (depth) to get volume Multiple (volume) x (7.5) to convert to METHOD 3: DURATION AND FLOW RATE Start Date and Time Line 1 End Date and Time Line 2 Total time elapsed of overflow (Subtract line 1 form line 2. Show time in minutes) Line 3 Average flow rate GPM Line 4 Total volume estimated (multiply line 3 and line 4) Line 5 2

3 SPILL DETAILS Spill Appearance Point (Select all that apply.) Final Spill Destination (Select all that apply.) Forced Main Gravity Mainline Inside Building or Structure Lateral Clean Out Building or Structure Drainage Channel Paved Surface Storm Drain Lateral Manhole Pump Station Street/Curb and Gutter Surface Water Unpaved Surface Estimated Spill Start Date/Time Spill Cause Explanation of Where Failure Occurred Air Relief Valve (ARV) / Blow-Off Valve (BOV) Failure Construction Diversion Failure UCB Staff Caused Spill or Damage Damage by Other Not Related to UCB Construction / Maintenance (specify): Debris from Construction Debris from Lateral Debris General Debris Rags Flow Exceeded Capacity Grease Deposition (FOG) Inappropriate Discharge to System Natural Disaster n-dispersables Operator Error Pipe Structural Problem / Failure Pipe Structural Problem / Failure Installation Pump Station Failure Controls Pump Station Failure Mechanical Pump Station Failure Power Rainfall Exceeded Design Root Intrusion Siphon Failure Vandalism Other (specify below) Was Spill Cause determined by a CCTV inspection? Where did the failure occur? Spill Response Activities Spill Response Completion Date and Time Air Relief Valve (ARV) / Blow-Off Valve (BOV) Force Main Gravity Mainline Lateral Manhole Cleaned up Mitigated Effects of Spill Contained all or portion of spill Restored flow Returned all spill to sanitary sewer system Pump Station - Controls Pump Station Mechanical Pump Station Power Siphon Returned portion of spill to sanitary sewer system Property Owner/Building Occupants Notified Other enforcement agency notified 3

4 Spill Corrective Action Taken Is there an on-going investigation? Reason for on-going investigation Added sewer to preventative maintenance program Adjusted schedule/method of preventative maintenance Enforcement action against source Inspected sewer using CCTV to determine cause Plan rehabilitation or replacement of sewer Repaired facilities or replaced defect Name of impacted surface waters Was spill associated with a storm event? Strawberry Creek Meeker Slough Codornices Creek t applicable no impacted surface water RESPONSE CREW (List all names along with their department or company) CALL CENTER INFORMATION Date and Time UC Berkeley operations/maintenance staff or EH&S was first notified of or discovered spill Complainant Information Name: Phone: Attach any work orders if available to the Incident Form. 4

5 FOR THE OFFICE OF ENVIRONMENT, HEALTH & SAFETY (EH&S) STAFF USE ONLY: Coordinates of Spill Latitude: Longitude: Diameter of sewer pipe at point of blockage or failure (optional) Material of sewer pipe at the point of blockage or failure (optional) Estimated age of sewer asset at the point of blockage or failure (in years) (optional) Visual inspection results from impacted receiving water Health warnings posted Water quality samples analyzed for Dissolved Oxygen Other chemical indicators (specify) Biological indicators (specify) water quality samples taken Explanation of water quality samples analyzed for Water quality sample results reported to County Health Agency Regional Water Quality Control Board Other (specify) water quality samples taken t applicable to this spill Cal Office of Emergency Services Control Number (if applicable) Cal Office of Emergency Services Called Date/Time (if applicable) INTERNAL STAFF REMINDERS Category 1: Submit Draft report within 3 business days of becoming aware of the SSO and certify within 15 calendar days of SSO end date. Category 2: Submit Draft report within 3 business days of becoming aware of the SSO and certify within 15 days of SSO end date. Category 3: Submit certified report within 30 calendar days of the end of the month in which SSO occurred. Draft Due: Certification Due: Create bcal event reminder for reporting Date Set: 5